Dr. Burtness reflects on the loss of Dr. Borbor, the only certified internist in Liberia who died of Ebola.

Idly looking at my phone earlier this week, I checked in on the New York Times website, and received the terrible news that Dr. Abraham Borbor had died of Ebola.

Dr. Borbor was the only trained internist in his country of Liberia, where he served as deputy chief medical doctor at the nation's largest hospital, the John F. Kennedy Medical Center in Monrovia.

He was one of the first humans to be treated with ZMapp, a very early phase cocktail of antibodies that has also been given to two American health workers infected with Ebola in this catastrophic epidemic. The Americans, Dr. Kent Brantly and Nancy Writebol, were flown to Emory University Hospital, where, in addition to ZMapp, they received expert medical and nursing care in an environment that provided every resource; Dr. Borbor was treated in Liberia.

According to accounts, Dr. Borbor seemed to be improving and on Saturday was able to walk around the hospital for a bit, but his condition worsened and he died on Sunday, August 24. The blow to John F. Kennedy Medical Center is profound, as its Chief Medical Officer, Dr. Samuel Brisbane, also succumbed to Ebola last week.

My connection to this story is personal. I knew Dr. Borbor when he was a resident at Kilimanjaro Christian Medical University College in Moshi, Tanzania, where I taught a short course in cancer medicine while on sabbatical in 2005. He was a great doctor, and he had that open delight in new medical knowledge that marks one's favorite students.

When I lectured the residents on tumor lysis syndrome, he told me about a child he had treated at home in Liberia for Burkitt's lymphoma, whose neck mass had melted away within a few days of treatment with oral cyclophosphamide, but who then died suddenly without any signs of infection. He had been puzzled by that case for 3 years, he said, and now understood what must have gone wrong.

A requirement to complete the residency at Kilimanjaro Christian Medical University College was an original thesis, and Dr. Borbor was stuck because the statistician was out on sick leave. Antiretroviral therapy had just become widely available in Moshi in 2004 to 2005, following investments by the United States Presidents' Emergency Plan for AIDs relief (PEPFAR), the Gates Foundation, and the Clinton Foundation, as well as long-term collaborations with Duke University and the London School of Hygiene & Tropical Medicine. His project centered on patients who initiated highly active antiretroviral therapy (HAART) and his primary objective was to determine baseline characteristics that predicted nonadherence to therapy.

I offered to help with some simple statistics, and we found that if he dichotomized adherence to therapy at 90% of tablets taken, there were only 2 factors that predicted nonadherence: the patient going to the pharmacy and being informed that the pharmacy was out of medication and waiting for a new shipment and the patient being intubated in the intensive care unit.

I remember that he was also worried that his results were not valid because he couldn't believe how rapidly the CD4 counts recovered after HAART was initiated, or how high the CD4 counts could be on treatment.

With these memories in mind, I personally mourn Dr. Borbor as the energetic, committed resident I knew in Moshi, but the loss of his training, experience, passion, and courage–he worked in the midst of an Ebola outbreak of tragic proportions, having already lost his closest colleague to the disease–is incalculable to his country. The BBC reported that the World Health Organization (WHO) issued a statement on the loss of health care personnel in West Africa1:

The WHO stated that the "heavy toll on health care workers" had consequences that further impeded control efforts, such as the closure of health facilities.

"Ebola has taken the lives of prominent doctors in Sierra Leona and Liberia, depriving these countries not only of experienced and dedicated medical care but also of inspiring national heroes," the WHO said in a statement.

"In many cases, medical staff are at risk because no protective equipment is available--not even gloves and face masks."

My admiration is boundless for the staff who persevere in caring for patients with Ebola in all the countries affected by this epidemic, including the medical staff, the workers who are building care stations for Doctors Without Borders and other similar organizations, and the health educators who seek to contain the spread of the disease. The scale of the response, however, seems completely inadequate and a more organized international response is clearly called for.

Furthermore, once the epidemic is contained and the survivors released from quarantine, Liberia will still have lost its only trained internist. This epidemic highlights how fragile the health systems in some developing nations can be. With this in mind, a more organized international response to the problem of building health care capacity is needed as well.

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